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of sucrose-containing foods, such as cakes and biscuits, there was insufficient evidence to conclude whether sugar has any association with breast cancer risk (Burley, 1998). Some subsequent case–control studies have also observed an increased risk for breast cancer among women with a relatively high consumption of sugar (Romieu et al., 2004) or sweet foods (Potischman et al., 2002). Subsequent prospective studies have mainly examined glycaemic index and glycaemic load (see below) rather than sucrose, and the few prospective data published on sucrose have not suggested that there is an association with breast cancer risk (Nielsen et al., 2005; Silvera et al., 2005b). Glycaemic index and glycaemic load. Seven prospective studies have investigated the associations of estimates of glycaemic index and glycaemic load with the risk for breast cancer (Table 4). For glycaemic index, the relative risks for a high index versus a low index ranged from 0.88. to 1.15, with a median of 1.03, and one of the relative risk was significantly greater than unity. For glycaemic load the relative risks for a high load versus a low load ranged from 0.87 to 1.19, with a median of 1.02 and none was statistically Table 4 Prospective studies of glycaemic index, glycaemic load and breast cancer risk significant. The available data therefore suggest that there is no association between either of these variables and the risk for breast cancer. Fibre. In previous systematic reviews, the World Cancer Research Fund (1997) concluded that, based largely on the findings from case–control studies, dietary fibre possibly decreases the risk of breast cancer, whereas the Department of Health UK report concluded simply that the evidence was inconsistent (Department of Health UK, 1998). In six subsequent prospective studies, the relative risks for high versus low consumption of total dietary fibre ranged from 0.58. to 1.08, with a median of 0.92 (Table 5), and one of these relative risks was significantly below unity. Analyses according to the food source of fibre, categorized as cereals, fruit and vegetables, did not show any significant associations with risk (Table 5). Overall, the data do not support the hypothesis that a high intake of dietary fibre might reduce breast cancer risk. In a prospective study, there was no clear association between the consumption of whole and refined grain and breast cancer risk (Nicodemus et al., 2001). First author and year Country Cases Menopausal status Comparison Glycaemic index, relative risk in highest category Glycaemic load, relative risk in highest category Cho et al., 2003 USA 714 Premenopausal Highest vs lowest fifth 1.05 (0.83–1.33) 1.06 (0.78–1.45) Jonas et al., 2003 USA 1442 Postmenopausal Highest vs lowest fifth 1.03 (0.87–1.22) 0.90 (0.76–1.08) Higginbotham et al., 2004b USA 946 Any Highest vs lowest fifth 1.03 (0.84–1.28) 1.01 (0.76–1.35) Holmes et al., 2004 USA 854 Premenopausal Highest vs lowest fifth 1.02 (0.82–1.28) 0.87 (0.70–1.12) Holmes et al., 2004 USA 2924 Postmenopausal Highest vs lowest fifth 1.15 (1.02–1.30) 1.03 (0.90–1.16) Nielsen et al., 2005 Denmark 634 Postmenopausal Per 10 units GI, per 100 units GL 0.94 (0.80–1.10) 1.04 (0.90–1.19) Silvera et al., 2005b Canada 1461 Any Top fifth 0.88 (0.63–1.22) 0.95 (0.79–1.14) Giles et al., 2006 Australia 324 Postmenopausal 1 s.d. 0.98 (0.88–1.10) 1.19 (0.93–1.52) Table 5 Prospective studies of dietary fibre and breast cancer risk First author and year Verhoeven et al., 1997 Terry et al., 2002 Cho et al., 2003 Holmes et al., 2004 Holmes et al., 2004 Mattisson et al., 2004 Giles et al., 2006 Country N cases Menopausal status Carbohydrates and cancer TJ Key and EA Spencer Comparison Relative risk in highest category Total fibre Cereal fibre Fruit fibre Vegetable fibre Netherlands 650 Postmenopausal Highest vs lowest fifth 0.83 (0.56–1.24) Canada 2536 Any Highest vs lowest fifth 0.92 (0.78–1.09) 0.90 (0.78–1.04) 1.07 (0.92–1.25) 0.90 (0.75–1.08) USA 714 Premenopausal Highest vs lowest fifth 0.88 (0.67–1.14) 0.91 (0.69–1.21) 1.13 (0.88–1.46) 0.97 (0.75–1.24) USA 854 Premenopausal Highest vs lowest fifth 0.99 (0.75–1.29) 0.99 (0.78–1.25) 0.86 (0.67–1.10) 0.95 (0.72–1.25) USA 2924 Postmenopausal Highest vs lowest fifth 0.96 (0.83–1.10) 1.08 (0.96–1.22) 0.92 (0.81–1.04) 0.94 (0.82–1.08) Sweden 342 Postmenopausal Highest vs lowest fifth 0.58 (0.40–0.84) Australia 324 Postmenopausal 1 s.d. 1.08 (0.92–1.26) 1.08 (0.95–1.23) 1.00 (0.88–1.13) 1.07 (0.95–1.20) S117 European Journal of Clinical Nutrition
S118 Cancer of the endometrium The development of endometrial cancer is strongly related to hormonal factors: both parity and use of the oral contraceptive pill reduce risk, whereas obesity and oestrogen-only hormone replacement therapy increase risk (Amant et al., 2005). There are few data on dietary carbohydrates and endometrial cancer risk; available results do not suggest an association of risk with total carbohydrates or with dietary fibre, but have suggested a possible association with high glycaemic index or glycaemic load (Jain et al., 2000; Augustin et al., 2003; Folsom et al., 2003; Silvera et al., 2005c). Since obesity increases risk by about threefold (Bergstrom et al., 2001; International Agency for Research on Cancer, 2002), it is possible that any associations with the glycaemic index or load of the diet may be explained by the effect of obesity. One prospective study has reported that high consumption of whole grain is associated with a reduced risk for endometrial cancer among women who had never used hormone replacement therapy (Kasum et al., 2001). Cancer of the cervix The principal cause of cancer of the cervix is persistent infection with oncogenic strains of the human papilloma virus (zur Hausen, 2002). The possibility that dietary factors might influence risk has been investigated in a number of studies, but these have focused largely on carotenoids and folic acid, with little attention given to carbohydrates (Garcia-Closas et al., 2005). Cancer of the ovary The development of ovarian cancer is strongly related to hormonal factors: both parity and use of the oral contraceptive pill reduce risk (Banks et al., 1997). Cramer et al. (1989) proposed that a high consumption of lactose might increase the risk for ovarian cancer, perhaps due to adverse effects of galactose on the ovaries. A number of studies have subsequently addressed this hypothesis. In a meta-analysis, Larsson et al. (2006b) concluded that the results of case– control studies were heterogeneous and did not suggest an association of lactose intake with the risk for ovarian cancer. However, they reported that in the three prospective studies examined there was evidence of a significant positive association between lactose consumption and ovarian cancer risk. A pooled analysis of 12 prospective studies, which included the three studies reviewed by Larsson et al. (2006b), reported that the risk for ovarian cancer was higher among people with the highest lactose intake than among those with the lowest lactose intake (relative risk 1.19 (1.01– 1.40)), although the test for a linear trend was not statistically significant (Genkinger et al., 2006). Overall, we conclude that a high intake of lactose is possibly associated with a small increase in the risk for ovarian cancer. As proposed by Cramer et al. (1989), one possible mechanism European Journal of Clinical Nutrition Carbohydrates and cancer TJ Key and EA Spencer for such an association is a direct adverse effect of galactose on the ovaries. For other carbohydrates, there are few data in relation to the risk for ovarian cancer (Schulz et al., 2004). Prostate cancer The causes of prostate cancer are poorly understood, and despite considerable research on the association of dietary factors with risk, no foods or nutrients have been clearly established as risk factors for this disease (Chan et al., 2005). Very little of this research has been focused on carbohydrates, and the data available have not suggested that there is an association between carbohydrate intake and prostate cancer risk (Chan et al., 2005). Bladder cancer The principal known risk factor for bladder cancer is tobacco (WHO, 2003b). Some studies have investigated the possible role of dietary factors, but the results have been inconclusive and little attention has been given to carbohydrates (Zeegers et al., 2004). Kidney cancer The aetiology of kidney cancer is poorly understood. Obesity increases risk, but the mechanism for this is unknown (Wolk et al., 1996). Studies have suggested possible associations with some dietary factors, but have focused mainly on the possible increased risks associated with the consumption of meat, eggs and dairy products and the possible reduction in risk associated with high intakes of fruit and vegetables. The results have been inconclusive and little attention has been given to carbohydrates (Wolk et al., 1996; Lindblad et al., 1997; Handa and Kreiger, 2002; Nicodemus et al., 2004; Rashidkhani et al., 2005). Other cancers For other cancers, not discussed above, little or no research has been conducted on whether dietary carbohydrates may have any direct impact on the development of disease. Obesity: associations with carbohydrate intake and cancer risk Obesity is an established risk factor for cancers of the oesophagus (adenocarcinoma) colorectum, breast, endometrium and kidney (International Agency for Research on Cancer, 2002; Key et al., 2004). The role of carbohydrates, especially sucrose and fibre, in the aetiology of obesity is discussed in the paper by van Dam and Seidell (2007) in this supplement. Where dietary carbohydrates contribute to obesity then they almost certainly also contribute to increasing the risk for these particular cancer sites, but this link may not be clearly seen in observational studies if the magnitude of both these associations is moderate or small.
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Comision Federal de la mejora regul
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Subject: MEXICO - Comments on PROY
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Item of PROY‐ NOM‐051 A.3.1 & A
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Annex 1.1: Ziesenitz, S.C.; 1996;
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Volume 61 Supplement 1 December 200
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Volume 61, Supplement 1, December 2
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S1 S5 S19 S40 S75 S100 S112 S122 S1
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FAO/WHO Scientific Update on carboh
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cardiovascular diseases and cancer)
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REVIEW Carbohydrate terminology and
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Table 2 Energy and macronutrient in
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are inulin and fructo oligosacchari
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Table 3 Principal physiological pro
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National Academy of Sciences in 200
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product contained X25% whole grain
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Henderson L, Gregory J, Swan G (200
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REVIEW Nutritional characterization
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Table 1 Nutritional characterizatio
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Table 2 Principles of carbohydrate
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Table 4 NSP in a selection of foods
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asked to consider both the ‘plant
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Table 5 Continued Plant-rich diet a
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account for any supplemented materi
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eaction vessels, with successive tr
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similar to the situation with sugar
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company working on dietary carbohyd
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van Dam RM, Seidell JC (2007). Carb
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2003). In establishing the energy v
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combustible energy of the fermentab
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glucose, starch, NSP) there is also
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generated through bioenergetic inef
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Table 4 cE, ME and NME, and content
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ME (Atwater general system) (Merill
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(o0.8 kg in the adult), increase af
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B1.4 MJ from protein in men, did no
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food and body weight, height or BMI
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esults may relate not only to the d
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ecologist, who is pre-occupied with
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Table 5 Effect of NSP (dietary fibr
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As already described, almost any ca
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Page 106 and 107: REVIEW Carbohydrate intake and obes
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Page 120 and 121: its carbohydrate content, whereas a
Page 122 and 123: Table 4 Continued Duration Interven
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Page 142 and 143: Meyer KA, Kushi LH, Jacobs Jr DR, S
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Page 146 and 147: Table 3 Prospective studies of diet
Page 150 and 151: Acrylamide Acrylamide is a chemical
Page 152 and 153: Nicodemus KK, Jacobs Jr DR, Folsom
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Page 156 and 157: Foods having very different nutrien
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Page 168 and 169: Dr Hans Englyst: Director and share
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Page 179 and 180: Annex 1.5: US Health Claims Regulat
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Page 183 and 184: Annex 1.6: “PalatinoseTM (isomalt
Page 185 and 186: Isomaltulose is tooth friendly, unl
Page 187 and 188: CONFIDENTIAL Regulatory Affairs & N
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Page 193 and 194: CONFIDENTIAL Plasma glucose change
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CONFIDENTIAL Regulatory Affairs & N
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CONFIDENTIAL References Regulatory
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Annex 1.8: Report from Imfeld (Univ
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Annex 2.2: Roberfroid, M.B., 1999;
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Annex 3.2: “Letter of no objectio
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1 Nutrition and Health Claims (CAC/
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Annex 3.2: “Letter of no objectio
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